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Carpal tunnel syndrome
Carpal tunnel syndrome (CTS) is a nerve compression syndrome caused when the median nerve, in the carpal tunnel of the wrist, becomes compressed. CTS can affect both wrists when it is known as bilateral CTS. After a wrist fracture, inflammation and bone displacement can compress the median nerve. With rheumatoid arthritis, the enlarged synovial lining of the tendons causes compression.
The main symptoms are numbness and tingling of the thumb, index finger, middle finger, and the thumb side of the ring finger, as well as pain in the hand and fingers. Symptoms are typically most troublesome at night. Many people sleep with their wrists bent, and the ensuing symptoms may lead to awakening. People wake less often at night if they wear a wrist splint. Untreated, and over years to decades, CTS causes loss of sensibility, weakness, and shrinkage (atrophy) of the thenar muscles at the base of the thumb. Work-related factors such as vibration, wrist extension or flexion, hand force, and repetitive strain are risk factors for CTS. Other risk factors include being female, obesity, diabetes, rheumatoid arthritis, thyroid disease, and genetics.
Diagnosis can be made with a high probability based on characteristic symptoms and signs. It can also be measured with electrodiagnostic tests.
Injection of corticosteroids may or may not alleviate symptoms better than simulated (placebo) injections. There is no evidence that corticosteroid injection sustainably alters the natural history of the disease, which seems to be a gradual progression of neuropathy. Surgery to cut the transverse carpal ligament is the only known disease modifying treatment.
The carpal tunnel is an anatomical compartment located at the base of the palm. Nine flexor tendons and the median nerve pass through the carpal tunnel, which is surrounded on three sides by the carpal bones that form an arch. The median nerve provides feeling or sensation to the thumb, index finger, long finger, and half of the ring finger. At the level of the wrist, the median nerve supplies the muscles at the base of the thumb that allow it to abduct, move away from the other four fingers, as well as move out of the plane of the palm. The carpal tunnel is located at the middle third of the base of the palm, bounded by the bony prominence of the scaphoid tubercle and trapezium at the base of the thumb, and the hamate hook that can be palpated along the axis of the ring finger. From the anatomical position, the carpal tunnel is bordered on the anterior surface by the transverse carpal ligament, also known as the flexor retinaculum. The flexor retinaculum is a strong, fibrous band that attaches to the pisiform and the hamulus of the hamate. The proximal boundary is the distal wrist skin crease, and the distal boundary is approximated by a line known as Kaplan's cardinal line. This line uses surface landmarks, and is drawn between the apex of the skin fold between the thumb and index finger to the palpated hamate hook.
The carpal bones and the transverse carpal ligament form the carpal tunnel. The median nerve passes through this space along with the flexor tendons. Increased compartmental pressure for any reason can squeeze the median nerve. Theoretically, increased pressure can interfere with normal intraneural blood flow, eventually causing a cascade of physiological changes in the nerve itself. There is a dose-respondent curve such that greater and longer periods of pressure are associated with greater nerve dysfunction. The symptoms and signs of carpal tunnel syndrome causes are hypertrophy of the synovial tissue surrounding the flexor tendons such as with rheumatoid arthritis.
Prolonged pressure can lead to a cascade of physiological changes in neural tissue. First, the blood-nerve barrier breaks down (increased permeability of perineureum and endothelial cells of endoneural blood vessels). If the pressure continues, the nerves will start the process of demyelination under the area of compression. This will result in abnormal nerve conduction even when the pressure is relieved leading to persistent sensory symptoms until remyelination can occur. If the compression continues and is severe enough, axons may be injured and Wallerian degeneration will occur. At this point there may be weakness and muscle atrophy, depending on the extent of axon damage.
The critical pressure above which the microcirculatory environment of a nerve becomes compromised depends on diastolic/systolic blood pressure. Higher blood pressure will require higher external pressure on the nerve to disrupt its microvascular environment. The critical pressure necessary to disrupt the blood supply of a nerve is approximately 30mm Hg below diastolic blood pressure or 45mm Hg below mean arterial pressure. For normohypertensive (normal blood pressure) adults, the average values for systolic blood pressure is 116mm Hg diastolic blood pressure is 69mm Hg. Using this data, the average person would become symptomatic with approximately 39mm Hg of pressure in the wrist (69 - 30 = 39 and 69 + (116 - 69)/3 - 45 ~ 40). Carpal tunnel syndrome patients tend to have elevated carpal tunnel pressures (12-31mm Hg) compared to controls (2.5 - 13mm Hg). Applying pressure to the carpal tunnel of normal subjects in a lab can produce mild neurophysiological changes at 30mm Hg with a rapid, complete sensory block at 60mm Hg. Carpal tunnel pressure may be affected by wrist movement/position, with flexion and extension capable of raising the tunnel pressure as high as 111mm Hg. Many of the activities associated with carpal tunnel symptoms such as driving, holding a phone, etc. involve flexing the wrist and it is likely due to an increase in carpal tunnel pressure during these activities.
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Carpal tunnel syndrome AI simulator
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Carpal tunnel syndrome
Carpal tunnel syndrome (CTS) is a nerve compression syndrome caused when the median nerve, in the carpal tunnel of the wrist, becomes compressed. CTS can affect both wrists when it is known as bilateral CTS. After a wrist fracture, inflammation and bone displacement can compress the median nerve. With rheumatoid arthritis, the enlarged synovial lining of the tendons causes compression.
The main symptoms are numbness and tingling of the thumb, index finger, middle finger, and the thumb side of the ring finger, as well as pain in the hand and fingers. Symptoms are typically most troublesome at night. Many people sleep with their wrists bent, and the ensuing symptoms may lead to awakening. People wake less often at night if they wear a wrist splint. Untreated, and over years to decades, CTS causes loss of sensibility, weakness, and shrinkage (atrophy) of the thenar muscles at the base of the thumb. Work-related factors such as vibration, wrist extension or flexion, hand force, and repetitive strain are risk factors for CTS. Other risk factors include being female, obesity, diabetes, rheumatoid arthritis, thyroid disease, and genetics.
Diagnosis can be made with a high probability based on characteristic symptoms and signs. It can also be measured with electrodiagnostic tests.
Injection of corticosteroids may or may not alleviate symptoms better than simulated (placebo) injections. There is no evidence that corticosteroid injection sustainably alters the natural history of the disease, which seems to be a gradual progression of neuropathy. Surgery to cut the transverse carpal ligament is the only known disease modifying treatment.
The carpal tunnel is an anatomical compartment located at the base of the palm. Nine flexor tendons and the median nerve pass through the carpal tunnel, which is surrounded on three sides by the carpal bones that form an arch. The median nerve provides feeling or sensation to the thumb, index finger, long finger, and half of the ring finger. At the level of the wrist, the median nerve supplies the muscles at the base of the thumb that allow it to abduct, move away from the other four fingers, as well as move out of the plane of the palm. The carpal tunnel is located at the middle third of the base of the palm, bounded by the bony prominence of the scaphoid tubercle and trapezium at the base of the thumb, and the hamate hook that can be palpated along the axis of the ring finger. From the anatomical position, the carpal tunnel is bordered on the anterior surface by the transverse carpal ligament, also known as the flexor retinaculum. The flexor retinaculum is a strong, fibrous band that attaches to the pisiform and the hamulus of the hamate. The proximal boundary is the distal wrist skin crease, and the distal boundary is approximated by a line known as Kaplan's cardinal line. This line uses surface landmarks, and is drawn between the apex of the skin fold between the thumb and index finger to the palpated hamate hook.
The carpal bones and the transverse carpal ligament form the carpal tunnel. The median nerve passes through this space along with the flexor tendons. Increased compartmental pressure for any reason can squeeze the median nerve. Theoretically, increased pressure can interfere with normal intraneural blood flow, eventually causing a cascade of physiological changes in the nerve itself. There is a dose-respondent curve such that greater and longer periods of pressure are associated with greater nerve dysfunction. The symptoms and signs of carpal tunnel syndrome causes are hypertrophy of the synovial tissue surrounding the flexor tendons such as with rheumatoid arthritis.
Prolonged pressure can lead to a cascade of physiological changes in neural tissue. First, the blood-nerve barrier breaks down (increased permeability of perineureum and endothelial cells of endoneural blood vessels). If the pressure continues, the nerves will start the process of demyelination under the area of compression. This will result in abnormal nerve conduction even when the pressure is relieved leading to persistent sensory symptoms until remyelination can occur. If the compression continues and is severe enough, axons may be injured and Wallerian degeneration will occur. At this point there may be weakness and muscle atrophy, depending on the extent of axon damage.
The critical pressure above which the microcirculatory environment of a nerve becomes compromised depends on diastolic/systolic blood pressure. Higher blood pressure will require higher external pressure on the nerve to disrupt its microvascular environment. The critical pressure necessary to disrupt the blood supply of a nerve is approximately 30mm Hg below diastolic blood pressure or 45mm Hg below mean arterial pressure. For normohypertensive (normal blood pressure) adults, the average values for systolic blood pressure is 116mm Hg diastolic blood pressure is 69mm Hg. Using this data, the average person would become symptomatic with approximately 39mm Hg of pressure in the wrist (69 - 30 = 39 and 69 + (116 - 69)/3 - 45 ~ 40). Carpal tunnel syndrome patients tend to have elevated carpal tunnel pressures (12-31mm Hg) compared to controls (2.5 - 13mm Hg). Applying pressure to the carpal tunnel of normal subjects in a lab can produce mild neurophysiological changes at 30mm Hg with a rapid, complete sensory block at 60mm Hg. Carpal tunnel pressure may be affected by wrist movement/position, with flexion and extension capable of raising the tunnel pressure as high as 111mm Hg. Many of the activities associated with carpal tunnel symptoms such as driving, holding a phone, etc. involve flexing the wrist and it is likely due to an increase in carpal tunnel pressure during these activities.